Healthcare Provider Details

I. General information

NPI: 1679156756
Provider Name (Legal Business Name): KATHERINE ELIZABETH TILLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHERINE ELIZABETH TEHANEY MD

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

640 JACKSON ST
SAINT PAUL MN
55101-2502
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-3456
  • Fax:
Mailing address:
  • Phone: 651-254-3456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number81218
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: